=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710051354
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IM SULZBACHER CENTER FOR THE HOMELESS, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2006
-----------------------------------------------------
Last Update Date | 03/23/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 611 E ADAMS ST
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32202-2847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-394-8070
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 611 E ADAMS ST
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32202-2847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-394-8070
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. KATHLEEN PATNEAU
-----------------------------------------------------
Credential | MPH
-----------------------------------------------------
Telephone | 904-394-8056
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QF0400X
-----------------------------------------------------
Taxonomy Name | Federally Qualified Health Center (FQHC)
-----------------------------------------------------
License Number | 6860320 00
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------